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GS*HS*52095*52095*251201*1212*1487113239*X*005010X279A1~
ST*270*000036434*005010X279A1~
BHT*0022*13*000036434*2512335*1212~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE MEDICARE ADVANTAGE 1*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*VOLAND*THERESA****MI*21296647~
DMG*D8*19570710*M~
DTP*291*RD8*20251201-20260301~
EQ*42~
EQ*30~
SE*14*000036434~
GE*1*36434~
IEA*1*000036434~